【作者】 饶璟；

【导师】 冯亚东；

【作者基本信息】 西南财经大学 ， 人口学， 2014， 博士

【摘要】 注意义务作为过失犯罪中的经典问题,将其置于医事犯罪的语境下进行研究,可以进一步揭示过失犯理论随着科学技术的进步而更迭的共时性。基于此,也可以深入探究过失犯理论与医疗之间的关系。从传统的医学领域来看,如果能够确定因果关系存在于医疗行为和治疗后果之间,那么,医疗过失的存在与否并不难认定。然而,高风险性质的治疗行为在现代医学领域之中运用广泛,其必然的影响是单纯的结果无价值论意义上的旧过失论本身不再能够适应现代医学的要求。而采用新过失论则将对过失的认识转向二元的行为无价值,更有利于鼓励医生履行结果回避义务,尽可能地使用对患者最有利的诊断和治疗手段,最大限度地维护患者的生命健康法益。但是,基于风险社会背景之下的超新过失论,抽象化地处理结果预见义务,并不利于对过失犯罪的认定。本论文的基本观点如下：第一、注意义务从抽象的角度来讲,是指不使得发生有害结果,而使意识集中谨慎行为的义务。过失必须是行为人具备预见可能性,不能是不可预见(unforeseeable)或者是意想不到(unexpected),换句话说,当行为人负有注意义务的时候,违反义务的标准就是指行为人的行为是否在所有情况下都是合理的,行为合理就没有过失可言,这样的判断采纳的是“理性人标准”但是,这个标准在具有专业技术知识领域的场合下,就会转变为“合理专业标准”。因此,囿于现有的技术,而导致无法预料的后果出现,或者属于不可抗力造成的不良后果,都不是注意义务的范围。第二、医术规则存在的目的,不仅仅是作为医师治疗疾病与伤痛的医术指导,更是为了保护病人避免受到不正确或者不正当的医疗行为的损害。因此,医师违反医术规则而进行医疗行为,就意味着医师超越了容许范围的风险而进行医疗行为。换句话说,医师在违背医疗准则的时候,应该对于非容许范围的额外风险具有预见可能性,对于额外风险的预见可能性是论证医疗过失能否成立的关键所在。第三、医疗水准只是一个抽象判断医师注意能力的标准,但是在医疗技术高度专门化的今天,必须考虑到医疗专门化因素。对于专科医师的注意义务标准,不能依照全科医师的注意义务标准,而应该以平均同科的医疗水平作为标准。专科医师对于专科之外的疾病,应该有说明转科就医的义务。第四、在治疗上应当要求医师采取当时医学上以及临床经验上证明具有实效性的措施,这是依照医学上所确保的基准,而这种基准是针对具有平均能力的专业医师所要求的义务,也就是所谓的“一个有经验的专业医师之基准”(Standard eines erfahrenden Facharztes)本论文的创新之处有如下几点：第一,通过剖析与医事注意义务相关联的案例,将医学上的临床经验与注意义务的相关的各项指标有机结合,以此对具体的涉医疑难刑事案件进行探讨。第二,在不同医疗环境下,细致考量医疗习惯、医学新知、并发症、紧急医疗等一系列问题与注意能力的关系,将注意义务的规定作为规制医事犯罪的刑事策略进行优化,说明医疗行为的注意义务是符合医疗水准的诊疗义务。第三,通过北大法宝、中国裁判文书网、我国台湾地区法源法律网以及日本国会图书馆、美国West-law等成熟的论文与案例数据库,试图立足中国现实生活条件而非简单地顺应世界潮流,以一种“中国语境”的态度破解中国问题。本文拟运用历史考察法、比较分析法、案例分析法等研究方法,结合各国家和地区历年来的疑难事案,通过对法律规范与刑事政策进行有机衔接,落实刑事一体化的研究路径；通过事实发现——理论嵌入——对策提供的论证模式,对医事犯罪中的注意义务作全景敞视式考察。本论文大致分为七个部分：第一部分为绪论,明确问题意识,设定范畴,并给出论文总体进路。第二部分：研究医事过失犯罪的核心是注意义务的界定。在本章中,首先,阐述刑法典中的犯罪过失和刑法理论上的业务过失,对于犯罪过失的理论进行梳理,对业务过失进行理论归纳。明确在因果行为理论的影响之下,认为过失犯的成立只不过是行为与结果之间的因果连结现象而已。也就是说,有谁在因果链条可以表现出来的意义之下引起了社会有害结果的发生,就符合了过失犯的要求。过失犯的成立,是由于行为人没有采取适当的回避法益侵害结果的措施,而违反了注意义务,且行为人对于这种法益侵害的结果具有预见可能性也有回避的可能。更需要说明的是,过失犯的成立还是需要二者之间因果关系链条存在与否的判断。其次,明确医疗行为的定义,探讨医事过失行为能否纳入业务过失的范畴。如果要求行为人对于可能发生一定结果的危险行为具有回避义务,应在其能力范围内使其尽到注意义务,以避免结果的发生。即使其属于从事业务的人员,也不能仅仅因为其具备从事一定业务的身份而不管其具体的注意能力如何,一概对其要求较高的注意义务,从而对其过失加重处罚。最后,结合一些案例,对于医疗行为除罪化的对立观点进行展示,但我国目前并没有医疗行为除罪化的空间。第三部分：在本章之中,对医事注意义务进行了模件化厘定。首先强调注意义务是犯罪过失的核心要素,明确了注意义务的内涵和预见可能性的内容；其次对注意义务的理论演变进程做了一些梳理,说明旧过失论中的注意义务是强调结果预见可能性的实现,而新过失论中的注意义务体现的是结果回避可能性的要求,对于超新过失论中的注意义务来说,更多地强调危惧感这一模糊的概念；复次,对医事注意义务进行整体鸟瞰,说明了医事注意义务的依据有：违反有约束力的规定是违背医事注意义务的标志,对医疗准则的违背亦构成对医事注意义务的违反,现有的医学文献、医学新知作为医事注意义务的基准以及具体的医疗水平、医疗习惯作为医事注意义务的判断基准。第四部分：本章主要阐述医事注意义务的判断基准。主要强调医事注意义务是符合医疗水准的诊疗义务。首先对于遵循医疗水准与承担医事过失犯罪责任的关联进行阐述,其次明确医疗水准的判断标杆是常规诊疗,对于常规诊疗的意义要旨进行了探讨,并着重说明对病情判断以及治疗决定有重要影响的是医师的亲自诊疗义务。探讨遵循医疗准则与承担医事过失犯罪责任之间的关联问题,必须明确的是医疗准则的意义以及医疗准则的征表机能；明确医疗水准的判断标杆是常规诊疗,在这里需要呈现的是犯罪过失中的注意义务判断基准之争论,然后界定医疗行为与犯罪过失责任的评价标准。本章探讨了医师违反亲自诊疗义务是否成立医事过失犯罪的问题,论述了对病情判断以及治疗决定有重要影响的医师亲自诊疗义务,并举出了医师违反亲自诊疗义务而成立刑事过失责任的相关实例。第五部分：本章中对医事过失犯罪进行了类型化考察,探讨了竞合过失类型与监督过失类型这两种过失犯罪类型。并对医疗行为之中的信赖原则进行了探讨,列举了相关案例进行说明。信赖原则的作用更明显地体现在医疗团队内部的责任分担之上,因为分工而形成的信赖是合作的必要前提,分工的依据是医院的内部组织制度和临床病案中的具体约定。根据医疗参与者之间的关系,可以将医疗分工分为水平分工和垂直分工两种模式。在医疗活动中,信赖原则的适用必须受到相当的限制,从而避免其被滥用。在组织医疗之中,在医疗分工者之间适用信赖原则,必须符合一系列的基本条件,可以分别从积极条件到消极条件两个方面加以说明。在本章之中,特别提到了对于医疗团队的误诊与信赖原则之适用问题,以案例为基础对之进行了分析。第六部分：医生的说明和病人的自我决定,可以在医患双方明确无碍的交流中得以实现。然而,在现实的人际互动中,医生应当说明的具体事项和说明的程度,医患双方对于医疗资讯信启、的理解分歧等等,是客观存在而且不容回避的问题。因视角的不同,可以将说明义务的判断标准分为医生标准、患者标准和折中标准三类。医师的裁量权与患者的自我决定权之间也存在紧张关系。医师的裁量权是基于医疗水准的范围之内,不能超出此界限,如果充分尊重自我决定权,那么,患者的一些特别要求就有可能超出医疗水准的范畴,可能会导致一些问题出现。这两者之间的关系可以用“P-E-C模式”进行说明。第七部分为结语,强调衡量和确定医事犯罪中的注意义务需注意的要点。更多还原

【Abstract】 With the advancement of science and technology, the criminal negligence of duty of care needs to be placed in the context of medical crime. Based on this, the theory of negligence and medicine needs further investigation.From the point of traditional medicine, if we can establish a causal relationship exists between medical treatment and treatment of the consequences, then medical negligence is not difficult to ensure. However, the medical treatment of high-risk behavior is widely used in modern medicine. With the inevitable impact, the old negligence theory (in sense of Erfolgsunwert) cannot meet the need of modern medicine, the new negligence theory (in sense of Handlungsunwert) encourage doctors to comply with one’s obligation of avoidable result. It as far as possible uses in the best interest of patients with the diagnosis and treatment, health legal interest (Rechtsgut).It maximizes the maintenance of the patient’s life. However, based on the background of risk society (Risikogesellschaft), super new negligence theory is not conducive to the cognizance of criminal negligence; on account of the theory abstract the obligation of predictable result.The basic point of this paper is as follows:First, from an abstract point of view, the duty of care is the result of not making the occurrence of harmful. The behavior should be cautious and concentrated. Negligence is the perpetrator must have foreseen the possibility. Negligence cannot be unforeseeable or unexpected, in other words, when the perpetrator has the duty of care, rational behavior has no fault, which is "reasonable person standard". Nevertheless, this standard will be transformed into a "reasonable professional standard", in the occasion of professional setting. Therefore, under the condition of existing technology, it is not the scope of the duty of care, which led to unforeseen consequences, or belongs to the adverse consequences caused by force majeure.Second, the purpose of medicine rules is not just as medicine guidance of physician treating disease and pain, but also to protect the patient to avoid damage to incorrect or improper medical practices. Therefore, physicians violate medical behavioral medicine rules, which means that the physician beyond the permissible range of risks and medical behavior. In other words, contrary to the physician in medical guidelines, the additional risk of non-scope should be foreseeable. It is the key point of medical negligence can be established, which is the foresee ability of the additional risk.Third, the level of physician is just abstract criterion attention ability. However, in the background of highly specialized medical technology, we must take into account the factors of medical specialization. Duty of care standard for specialist physicians is not in accordance with the duty of care standard for general practitioner, and the average medical standards should be the same family as the standard. When the disease outside the department, specialist should have the obligation of transferred medical treatment.Fourth, the treatment should require physicians to take measures proven effectiveness of clinical experience and medical care. At the time, it is ensured in accordance with the medical basis, and this benchmark is for a physician to be an average capacity of its obligations, which is called "an experienced physician’s benchmark"(Standard eines erfahrenden Facharztes).The innovation of this paper is as follows:First, through medical cases analysis which on the attentive liability of crime of medical negligence, it is associated with the relevant indicators of clinical experience and the combination of the duty of care in medicine, in order for a specific health-related criminal cases to discuss. Second, in different medical environment, detailed consideration of the relationship between health habits, medical knowledge, complications, emergency medical and other issues with the attention ability, to pay attention to regulatory obligations as a criminal strategies of medical practices to optimize, which described the duty of care is consistent with standard medical treatment obligations. Third, by China law info, Judicial Opinions of China, Net Source of Law in Taiwan, and Japan Legal Network Library of Congress, the West-law in United States and other mature database and case papers, the author is based on the living conditions of China rather than simply followed the world trend, in a "Chinese context" to crack real Chinese problem.This paper intends to use the methods of historical, comparative analysis, case analysis and other research methods, combined with various cases of countries and regions over the years, in this way of convergence of legal norms and criminal policies, implementation of the research approach of Criminal Integration. Through fact-finding, theoretical introduction, recommend appropriate solutions, the author inspect the attentive ability of medical negligence crime in panoptic-style.This article is broadly divided into seven sections:The first part is an introduction, a clear awareness of the problem, set the scope of the paper and gives the overall approach.Part II:Medical research is to define the core of criminal negligence of duty of care. In this chapter, first described criminal negligence in the Criminal Code and the theory of professional negligence (Professionelle Fahrlassigkeit), and summarized the theory of criminal negligence and professional negligence theory. It make the theory clear that under the influence of behavioral theory of causation, which is just delinquents established a causal link between the conduct and the results of the phenomenon. That is, who caused the occurrence of socially harmful results under the causal chain can be expressed the meaning which meets the requirements of the delinquents. The establishment of the fault committed, is due to the behavior of people do not take measures against the results of the appropriate legal interests avoidance, and breach of the duty of care, and the perpetrator have foreseen the outcome and the ability to avoid. More things need to be noted that the establishment of criminal negligence need a chain of causality between the action and outcome. Secondly, a clear definition of medical practice, and to explore whether the category of medical negligence should embrace professional negligence theory. If the perpetrator may occur dangerous behavior with a certain outcome, one should evade obligations and do to the duty of care, in order to avoid the occurrence of the results within their capabilities. Even if it belongs to professionals, but also just because it has engaged in certain business identity regardless of its specific attention ability, that any of them require a higher duty of care, thereby aggravating their fault. Finally, a number of cases, the decriminalization of medical practices on display, but there is no medical practices of decriminalization space.Part III:Among the chapter on medical duty of care were based on modules. First emphasized the duty of care is a core element of criminal negligence, it clears up the content of duty of care predictable possibilities, and cleans up the evolution process of theory of the duty of care, indicating that the old duty of care negligence theory is likely to emphasize the results foreseen of implementation, and the new duty of care in negligence theory is the result reflects the possibility of avoiding the requirements of the duty of care for negligence, over the new theory is concerned, more emphasis apprehensive feeling which is a vague concept; Thirdly, on the overall aerial view of medical duty of care shows the medical duty of care generally based on breach of a binding requirement, which is contrary to the medical duty of care, medical guidelines violation also constitutes medical attention breach of the obligation, the existing medical literature, medical knowledge as a duty of care medical reference and specific medical standards, health habits as a benchmark to determine medical attention obligations.Part IV:This chapter covers the medical attention to determine the reference obligation. The main emphasis on the duty of care is in line with medical standards of medical treatment obligations. First, for the association to follow medical standards and commitment to medical criminal negligence liability elaborate, which followed by a clear medical standards to determine the benchmark conventional treatment, the conventional treatment of the significance gist should be discussed, and highlights an important influence on the condition judgment and treatment decisions of personally clinic duty physicians. Discussion to follow medical standards and bear the medical problems associated with criminal negligence liability between tables, must clears up the intrinsic functional significance and medical standards of medical standards; specific medical standards to determine the benchmark conventional treatment, where the need to render the criminal negligence, the criterion of the duty of care debate, and then define the behavior and criminal negligence medical evaluation criteria. This chapter discuss the physician violation of personally clinics obligation is established medical problem criminal negligence, the important influence of the disease judgment and treatment decisions physicians personally clinic duty, citing a physician violates personally clinics obligations established criminal negligence of relevant examples.Part V:Chapter on medical criminal negligence was typed expedition to explore the competing types of fault types and supervisory negligence. Medical practices and trust among the principles discussed, citing relevant cases described. Trust principle role is more evident on the interior of the medical team shared responsibility; trust formed because of the division of labor, which is a necessary prerequisite for cooperation, the division is based on the internal organization of the hospital’s medical records and clinical systems in specific conventions. According to the medical relationship between the participants, the medical division of labor can be divided into two modes horizontal and vertical division. In the medical activities, the application of the principle of reliance must be fairly limited, so as to avoid its abuse. Among health care organization in the medical division between those, who apply the principles of trust must meet a series of basic conditions, that can be described separately from positive to negative conditions. Among the chapter, with particular reference to the application of the medical team misdiagnosed and trust principles to cases based on the analysis.Part VI:Doctor’s instructions and patient self-determination can be realized without problems in communication between doctors and patients. However, in real human interaction, the physician should explain specific matters and the extent described medical news and information for both doctors and patients to understand the differences and so on, which are objective and unavoidable issue. Because of different perspectives can be described criteria into physician obligations standards, criteria and compromise patient standard categories. There are also tensions between discretion and the right to self-determination of the patient’s physician. Physician’s discretion based on the scope of the medical standards, cannot exceed this boundary, if physician fully respect the right of self-determination, there will be some special requirements which may exceed the scope of the patient’s medical standards and cause some problems. This relationship between the two can be explained by the "PEC mode".Part VII is the conclusion which emphasizes the elements of attentive liability (duty of care) in the medical crime.更多还原